A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care.

AIMS: To compare the effectiveness of care delivered by nurses to the usual care delivered by general practitioners, in adult patients requesting same day appointments in primary care practices in Catalonia (Spain). BACKGROUND: Same day appointments conducted by nurses are characterized by high patient satisfaction and a high resolution index. The profile of nursing and the organization of primary care services in our country differ from other countries. DESIGN: Multicentre, randomized, unblinded clinical trial with two parallel groups. METHODS: Patients were randomized to an intervention group (seen by nurses trained to respond to low complexity problems) or a control group (seen by the general practitioner) using an automatic probabilistic function. SETTING: 38 primary care practices in Catalonia, 142 general practitioners and 155 nurses participated. Population study: ≥ 18-year-old patients who requested a same day consultation. Recruitment period: January-May, 2009. Of the 1,461 randomized patients, 92.5% completed the study. MAIN OUTCOME MEASURES: resolution of symptoms and patient satisfaction 2 weeks after the visit. RESULTS: Seven hundred and fifty-three patients were assigned to the intervention group and 708 to the control group. Nurses successfully solved 86.3% of the cases. We did not observe any differences in resolution of symptoms or patient satisfaction between the groups. CONCLUSIONS: Nurses trained specifically to resolve acute health problems of low complexity give comparable quality of care to that provided by general practitioners in terms of resolution of the problem 15 days after the visit and in patient satisfaction with the visit.

An integrated prognostic model for diffuse large B-cell lymphoma treated with immunochemotherapy.

Diffuse large B-cell lymphoma (DLBCL), the most frequent non-Hodgkin's lymphoma subtype, is characterized by strong biological, morphological, and clinical heterogeneity, but patients are treated with immunochemotherapy in a relatively homogeneous way. Here, we have used a customized NanoString platform to analyze a series of 197 homogeneously treated DLBCL cases. The platform includes the most relevant genes or signatures known to be useful for predicting response to R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone) in DLBCL cases. We generated a risk score that combines the International Prognostic Index with cell of origin and double expression of MYC/BCL2, and stratified the series into three groups, yielding hazard ratios from 0.15 to 5.49 for overall survival, and from 0.17 to 5.04 for progression-free survival. Group differences were highly significant (p < 0.0001), and the scoring system was applicable to younger patients (<60 years of age) and patients with advanced or localized stages of the disease. Results were validated in an independent dataset from 166 DLBCL patients treated in two distinct clinical trials. This risk score combines clinical and biological data in a model that can be used to integrate biological variables into the prognostic models for DLBCL cases.

Secretory breast carcinoma in a 63-year-old man.

A secretory carcinoma of the breast, associated with axillary node metastasis, occurred in a 63-year-old man. Secretory breast carcinoma is a rare variant of breast carcinoma, but it is the commonest type seen in children, although most of the cases have been described in females. Here, we describe a case in an adult man.

Safety of intramuscular influenza vaccine in patients receiving oral anticoagulation therapy: a single blinded multi-centre randomized controlled clinical trial.

BACKGROUND: Influenza vaccines are recommended for administration by the intramuscular route. However, many physicians use the subcutaneous route for patients receiving an oral anticoagulant because this route is thought to induce fewer hemorrhagic side effects. Our aim is to assess the safety of intramuscular administration of influenza vaccine in patients on oral anticoagulation therapy. DESIGN: Randomised, controlled, single blinded, multi-centre clinical trial. SETTING: 4 primary care practices in Barcelona, Spain. PARTICIPANTS: 229 patients on oral anticoagulation therapy eligible for influenza vaccine during the 2003-2004 season. INTERVENTIONS: intramuscular administration of influenza vaccine in the experimental group (129 patients) compared to subcutaneous administration in the control group (100 patients). PRIMARY OUTCOME: change in the circumference of the arm at the site of injection at 24 hours. SECONDARY OUTCOMES: appearance of local reactions and pain at 24 hours and at 10 days; change in INR (International Normalized Ratio) at 24 hours and at 10 days. Analysis was by intention to treat using the 95% confidence intervals of the proportions or mean differences. RESULTS: Baseline variables in the two groups were similar. No major side effects or major haemorrhage during the follow-up period were reported. No significant differences were observed in the primary outcome between the two groups. The appearance of local adverse reactions was more frequent in the subcutaneous administration group (37,4% vs. 17,4%, 95% confidence interval of the difference 8,2% to 31,8%). CONCLUSION: This study shows that the intramuscular administration route of influenza vaccine in patients on anticoagulant therapy does not have more side effects than the subcutaneous administration route. REGISTRATION NUMBER: NCT00137579 at clinicaltrials.gov.

Expression of CDX2, cytokeratins 7 and 20 in sinonasal intestinal-type adenocarcinoma.

CDX2 is a transcription factor expressed by intestinal epithelium. It is considered as a sensitive marker for a colorectal or-less frequently-gastric origin of adenocarcinomas. The pattern of coordinated expression of cytokeratin (CK) 7 and CK20 is also useful for the diagnosis of the origin of metastatic adenocarcinomas. Expression of CDX2, CK7 and CK20 was investigated in 14 cases of sinonasal intestinal-type adenocarcinoma (SIA), a particular tumor with an enteric-cell-type appearance. Formalin-fixed, paraffin embedded tissue sections were immunostained with monoclonal antibodies using the biotin-labeled streptavidin technique. All of the cases expressed CDX2, being stained 50 to 100% of the tumor cells (mean: 87.2%). CK7 positivity was detected in 8 cases (57.1%), with the staining of 10 to 100% of cells (mean: 65.6%), and CK20 was found in all the tumors (10 to 100% of cells; mean: 78.8%). The histologic resemblance between SIA and colorectal adenocarcinoma is reinforced by the expression of CDX2 and CK20, which are virtually constant in both neoplasms. CDX2 seems to be a marker for cellular phenotype better than an indicator of the origin of adenocarcinomas. CK7 is expressed in SIA less frequently than in colonic adenocarcinoma, but with a rate similar to the subset of rectal tumors, making the differential diagnosis between the two neoplasms difficult.

A prospective multicenter study of the effect of patient education on acceptability of generic prescribing in general practice.

The purpose of the study was to assess patients' acceptability of the substitution of brand-name drugs for generic drugs in the primary health care prescribing practices for chronic conditions. A prospective randomised multicentre study was conducted over a 12-month period in which patients taking medications for chronic disorders received an educational intervention on generic drugs at the time they attended different general practices in the city of Barcelona (Spain) for repeat prescribing. Twenty-seven public primary care centres were randomised to the intervention group (eight centres) or the control group (19 centres). Of 4620 patients in the intervention group that received verbal information and handout materials on advantages and disadvantages of generic equivalents and brand-name drugs, 98.9% of them agreed to receive a generic formulation. The primary care centre and the class of drug were associated with statistically significant differences in the percentage of acceptance of generic drugs. In the overall population, generic prescribing in the intervention practices increased to 5.9 as compared with 2.8% in controls. In summary, individual educational intervention in patients with repeat prescribing resulted in a high rate of generic acceptability. The intervention might stimulate the practitioner's motivation, behaviour and knowledge of generic forms.

[Factors related to experiencing respiratory failure in cases of opiate overdose for which care was provided in an open setting. Barcelona, Spain]. / Factores asociados a presentar parada respiratoria en las sobredosis por opiáceos atendidas en un escenario abierto de consumo de drogas en Barcelona.

BACKGROUND: To determine the factors associated with respiratory arrest in opiate overdoses (coma, pupillary miosis, respiratory depression, and response to naloxone) among injecting drug users in the Can Tunis quarter of Barcelona. METHODS: We ran a transversal observational study where all overdoses assisted between March, 2001 and June, 2002. After overdose treatment, data were collected using a standard questionnaire, including: patients' sociodemographic data, opiate and other substances' use prior to overdose, clinical signs and symptoms presented, and medical intervention received, by way of a standardised questionnaire. Logistic regression was used as a tool for analysis. RESULTS: Of 222 opiate overdose cases, 60.8% showed respiratory arrest. Of all risk factors tested, only prior abstinence heroin abstinence for 2 weeks or longer days (OR=1.893; p=0.04), and no previous consumption of benzodiazepines (OR:0.462; p=0.017), proved to have a statistically significant association with suffering a respiratory arrest. Concomitant use of alcohol, cocaine or methadone appeared not associated with suffering respiratory arrest in opiate overdose. CONCLUSIONS: The main risk factor for respiratory arrest in opiate overdoses was a prior abstinence period of more than 2 weeks. Benzodiazepines use was associated with absence of respiratory arrest in overdose cases. Alcohol or methadone use, as well as the use of larger quantities of heroin, was not associated with suffering respiratory arrest in opiate overdoses. A study of other factors, not included in this study, and that could interfere with our results, should be considered for their possible relationship to benzodiazepine use as well as to absence of respiratory arrest in overdose cases.

Creation of a synthetic indicator of quality of care as a clinical management standard in primary care.

INTRODUCTION: The development of electronic medical records has allowed the creation of new quality indicators in healthcare. Among them, synthetic indicators facilitate global interpretation of results and comparisons between professionals. METHODS: A healthcare quality standard (EQA, the Catalan acronym for Estàndard de Qualitat Assistencial) was constructed to serve as a synthetic indicator to measure the quality of care provided by primary care professionals in Catalonia (Spain). The project phases were to establish the reference population; select health problems to be included; define, select and deliberate about subindicators; and construct and publish the EQA. RESULTS: Construction of the EQA involved 107 healthcare professionals, and 91 health problems were included. In addition, 133 experts were consulted, who proposed a total of 339 indicators. After systematic paired comparison, 61 indicators were selected to create the synthetic indicator. The EQA is now calculated on a monthly basis for more than 8000 healthcare professionals using an automated process that extracts data from electronic medical records; results are published on a follow-up website. Along with the use of the online EQA results tool, there has been an ongoing improvement in most of the quality of care indicators. CONCLUSIONS: Creation of the EQA has proven to be useful for the measurement of the quality of care of primary care services. Also an improvement trend over 5 years is shown across most of the measured indicators. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/2193-1801-2-51) contains supplementary material, which is available to authorized users.

Risk of advanced proximal neoplasms according to distal colorectal findings: comparison of sigmoidoscopy-based strategies.

BACKGROUND: Screening for colorectal cancer with sigmoidoscopy benefits from the fact that distal findings predict the risk of advanced proximal neoplasms (APNs). This study was aimed at comparing the existing strategies of postsigmoidoscopy referral to colonoscopy in terms of accuracy and resources needed. METHODS: Asymptomatic individuals aged 50-69 years were eligible for a randomized controlled trial designed to compare colonoscopy and fecal immunochemical test. Sigmoidoscopy yield was estimated from results obtained in the colonoscopy arm according to three sets of criteria of colonoscopy referral (from those proposed in the UK Flexible Sigmoidoscopy, Screening for COlon REctum [SCORE], and Norwegian Colorectal Cancer Prevention [NORCCAP] trials). Advanced neoplasm detection rate, sensitivity, specificity, and number of individuals needed to refer for colonoscopy to detect one APN were calculated. Logistic regression analysis was performed to identify distal findings associated with APN. All statistical tests were two-sided. RESULTS: APN was found in 255 of 5059 (5.0%) individuals. Fulfillment of UK (6.2%), SCORE (12.0%), and NORCCAP (17.9%) criteria varied statistically significantly (P < .001). The NORCCAP strategy obtained the highest sensitivity for APN detection (36.9%), and the UK approach reached the highest specificity (94.6%). The number of individuals needed to refer for colonoscopy to detect one APN was 6 (95% confidence interval [CI] = 4 to 7), 8 (95% CI = 6 to 9), and 10 (95% CI = 8 to 12) when the UK, SCORE, and NORCCAP criteria were used, respectively. The logistic regression analysis identified distal adenoma ≥10 mm (odds ratio = 3.77; 95% CI = 2.52 to 5.65) as the strongest independent predictor of APN. CONCLUSIONS: Whereas the NORCCAP criteria achieved the highest sensitivity for APN detection, the UK recommendations benefited from the lowest number of individuals needed to refer for colonoscopy.

[Poroid hidradenoma]. / Hidroadenoma poroide.

Poroid hidradenoma is a recently described variant of eccrine poroma. This neoplasm presents structural findings of hidradenoma (solid and cystic areas) and cytological characteristics of poromas (poroid and cuticular cells, the latter showing ductal differentiation). We present a case of poroid hidradenoma in a 74-year-old woman, who consulted her physician because of a nodular lesion on the left buttock.